Q. How does a NICU doctor determine when a baby needs to be on a ventilator, needs a CPAP, needs a nasal canula or is ready to breathe on his/her own?

A. This is a complex question because so much is involved in making these decisions, and each baby is a unique individual. In general, the most support is needed when the lungs are affected by problems like respiratory distress syndrome or pneumonia. The neonatal team will be continuously examining a variety of factors including your baby's vital signs (heart rate, respiratory rate, blood pressure), oxygen saturation, and how hard your baby is working to breathe. The team will also look at tests such as chest xrays and blood gases (measuring the acid-base balance, and oxygen level directly in the blood). If your neonatologist decides your baby needs surfactant replacement therapy for respiratory distress syndrome, your baby can only receive that through a breathing tube, and a ventilator will be needed for at least a short while until the lungs improve.

If your baby needs a ventilator, your neonatologist will talk with you every day about what the goals are, and what the process is for weaning off this support. Very tiny babies with sick lungs sometimes need this support for weeks, but most recover without significant problems. The good news is that there are now many ventilators designed especially for small babies, and we
are able to provide this support with much less trauma to the lungs than even 10 years ago.

Even when the lungs are healthy, smaller babies often need some help breathing. In large part this is because the chest wall is a bit frail, and can need some support to prevent the air sacs in the lung from collapsing. We try to let even the tiniest babies do as much as possible on their own, but many need some help with a CPAP device ("nasal prongs" hooked up to a machine that delivers a small amount extra pressure support) or even a ventilator. Some babies need this support because they have apnea (periods where they forget to breathe).

A nasal cannula is used when just a bit of oxygen is needed. Sometimes even the air flow of the cannula helps babies with apnea remember to breathe. A cannula is sometimes needed for a long time in the most premature babies, but this can be used at home pretty easily if your neonatologist decides this is best.

The neonatology team works hard to make sure the support a baby receives matches his or her needs as exactly as possible. The philosophy of what ideal respiratory support is varies somewhat from physician to physician, so be sure to ask your neonatologist these questions too.